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118 Cards in this Set
- Front
- Back
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What do you say to a patient when they are extubated? |
Tell them to relax and don’t talk |
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Meds for patients on Vent? |
Paralytics and sedatives Propofol, pancuronium |
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Anaphylactic shock |
Airway airway airway Wheezing Epinephrine (give first) Benadryl Oxygen Remove allergens Stop infusion if it’s a reaction to blood |
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Which medication for DM is held for procedure’s with dye? |
Metformin |
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Care of a MI patient |
M- morphine O- oxygen N- nitro A- ASA Cardiac enzymes tell the degree of damage 12 lead ECG tells where the damage is |
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Care of patient with possible stroke |
F- facial droop A- arm drift S- speech impairment T- time to call 911 Most concerning pt statement “I have the worst ha of my life” |
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How long from onset of stroke can TPA be given? |
3 to 4.5 hours |
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Manifestations of Left sided stroke |
Dysphasia Reading or writing problems Right hemiparesis Right side neglect |
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Manifestations of Right sided stroke |
Lack of impulse control Behavioral changes Left hemiparesis Left side neglect |
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Care of patient with wound dehisced |
Cover with moist dressing |
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Care of pt with fracture |
Neurovascular Checks Don’t put anything down the cast |
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Triage during a disaster |
Red (immediate) Yellow ( delayed) Green (minimal) Black (expected) |
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Care of post op chest surgery pt. (CABG) |
Assess for bleeding & fluid status Replace electrolytes prn Monitor for dysrhythmias Pain management DVT prevention Incentive spirometer |
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Pain meds given after CABG |
PCA, morphine, dilauded |
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Care of a patient with ulcerative colitis |
Keep fluid and electrolyte balance, rest bowel diet- chicken and rice brat diet - bananas, rice, applesauce, toast |
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care of patient with allergic reaction |
blood transfusion stop get new tubing infuse NS. remove allergens c/o back px, hives, trouble breathing, swellin g of the lips mouth, give epinephrine first maintain airway |
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The nurse is scheduling a client for a cardiac catheterization. The client has type 2 diabetes and takes metformin. Which action will the nurse take prior to scheduling the procedure?
a. The nurse will instruct the client to have a fasting A1C and glucose tolerance test prior to the procedure .b. The nurse will instruct the client to eat a low carbohydrate diet three days prior to the procedure. c. The nurse will instruct the client to hold the metformin for 24 hours before the procedure and 48 hours after the procedure. d. The nurse instructs the client to take all medications the morning of the procedure but not to drink or eat afterwards. |
c. The nurse will instruct the client to hold the metformin for 24 hours before the procedure and 48 hours after the procedure.
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The nurse is assessing an elderly client admitted with a diagnosis of chronic heart failure (HF). The spouse asks the nurse the primary cause for HF, and the nurse responds that HF may be caused by:
a. Endocarditis b. Pleural effusion c. Atherosclerosis d. Atrial-septal defect |
c. Atherosclerosis
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The nurse is caring for a hospitalized client with admitting diagnosis of right-sided heart failure (HF). What assessment finding is most consistent with the client's diagnosis?
a. Pulmonary edema b. Distended neck veins c. Dry hacking cough d. Orthopnea |
b. Distended neck veins
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The nurse is providing discharge education on fluid balance monitoring to a client with a new diagnosis of right-sided heart failure. The nurse will stress which priority instruction for monitoring fluid balance?
a. Weigh daily at the same time in similar clothingb. Take self-pulse rates and report findings below 60c. Take blood pressure at the same time dailyd. Bowel movements should be logged |
a. Weigh daily at the same time in similar clothing
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The nurse is caring for an older client who was admitted for extreme weakness, dizziness, and orthopnea. A diagnosis of heart failure is confirmed. Which of the following tests is helpful in determining the diagnosis of heart failure?
a. Electrolyte Panel b. Liver Function Panel c. 12-lead Electrocardiogram d. Brain natriuretic peptide (BNP) |
d. Brain natriuretic peptide (BNP)
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A client has been admitted to the hospital unit with angina. The client's spouse expresses understanding of the condition when the nurse overhears the family member making which statement on the phone?
a. "He has had a small heart attack and is causing him pain" b. "The reduced blood flow to his heart muscle is causing pain." c. "The heart valve is blocked and causing pain in his heart." d. "He has a clot in his lung causing pain in his chest."
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c. "The heart valve is blocked and causing pain in his heart."
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A client is admitted to the hospital with the following rhythm. Which of these co-morbidities could be the cause of this rhythm? Select all that apply.
a. Valvular disease b. Heart failure. c. Chronic obstructive pulmonary disease. d. Pulmonary hypertension. e. Bacterial pneumonia. |
a. Valvular disease
b. Heart failure. c. Chronic obstructive pulmonary disease. d. Pulmonary hypertension. |
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A client arrives in the emergency department with chest pain #7 out of #10 on the pain scale; a troponin level of 0.01 ng/ml on the first lab draw. When placed on the ECG monitor reveals the following rhythm: Which is the priority intervention by the nurse?
a. Continue to monitor the client for a heart attack since the cardiac rhythm and troponin level is abnormal. b. Continue to assess the client on the cardiac monitor, but ask the health care provider to check other options since the cardiac rhythm is normal sinus rhythm and the troponin level is low. c. Rush the client to the cardiac catheter lab to be catheterized since both the rhythm and troponin levels are abnormal. d. Administer nitroglycerin 0.4 mg SL every 5 minutes X 3 and if no relief, give Morphine 2 mg IVP as ordered. |
b. Continue to assess the client on the cardiac monitor, but ask the health care provider to check other options since the cardiac rhythm is normal sinus rhythm and the troponin level is low.
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The nurse is performing an assessment on a client with a history of cardiovascular disease, diabetes, hypertension, and hypothyroidism. The client is experiencing exhaustion with simple activities of daily living and short ambulation, and states a 5 pound weight gain over 4 days. Assessment reveals 4+ edema to lower extremities and jugular distention. The nurse will report findings to the health care provider and anticipates which medical condition?
a. Acute pericarditis b. Myocardial infarction c. Left-sided heart failure d. Right-sided heart failure |
d. Right-sided heart failure
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The nurse is assessing a client admitted to the telemetry unit from the Emergency Department with complaints of increasing shortness of breath, and is coughing pink-tinged frothy sputum. During the history assessment, the nurse documents a history of left-sided heart failure. The nurse recognizes the presenting signs and symptoms of which health problem?
a. Right-sided heart failure b. Acute pulmonary edema c. Bacterial pneumonia d. Myocardial infarction |
b. Acute pulmonary edema
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A client comes into the Emergency Department (ED) with full-thickness electrical burns covering the hands, arms, and frontal trunk. According to the Rule of 9's, what is the client's total body surface area (TBSA)?
a. 18% TBSA b. 25% TBSA c. 30% TBSA d. 36% TBSA |
d. 36% TBSA
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A client was moved from the ED to the burn unit and is the acute phase of burn management. The client has full-thickness burns to the anterior trunk, perineum, and sacral areas of the body. The nurse is creating a care plan for the client. Which is the most appropriate priority diagnosis at this time?
a. Risk for fluid volume overload b. Risk for infection c. Impaired skin integrity d. Impaired physical mobility |
b. Risk for infection
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Which steps help to manage infection control with PICC line dressing changes? Select all that apply.
a. Ensure the client and nurse wear a mask prior to beginning the dressing change. b. Don sterile gloves after removing previous dressing c. Use skin prep to help secure dressing to skin and to protect the skin. d. Scrub skin with chlorhexidine using sterile gauze to hold the line in place. e. Use alcohol sponge to clean skin around Statlock. |
a. Ensure the client and nurse wear a mask prior to beginning the dressing change.
b. Don sterile gloves after removing previous dressing. d. Scrub skin with chlorhexidine using sterile gauze to hold the line in place. e. Use alcohol sponge to clean skin around Statlock. |
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A client has pneumonia with a urinary tract infection (UTI) and has been hospitalized for 2 days. When the nurse begins her shift, she assesses that the client's temperature is 102.5F, BP 70/38, HR 140, RR 38, very weak, has chills, a slow capillary refill, cool, pale, clammy skin, and labs reveal a WBC of 19,000. Which of these does the nurse suspect the client has developed?
a. Septic shock from sepsis b. Cardiogenic shock from heart failure c. Anaphylactic shock from a drug reaction d. Neurogenic shock from a spinal cord injury |
a. Septic shock from sepsis
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The ambulance brings a client with multiple bee stings to the ED. The client is exhibiting dyspnea, hives over the body, and hypotension. Which of these would the nurse implement as priority?
a. Epinephrine b. Albuterol sulfate c. Dexamethasone d. Diphenhydramine |
a. Epinephrine
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A client is admitted to the unit with cardiogenic shock from a heart attack. After receiving health care provider orders, which intervention medications will the nurse anticipate preparing? Select all that apply.
a. Dopamine b. Digoxin c. Diphenhydramine d. Daunorubicin e. Dexamethasone |
a. Dopamine
b. Digoxin |
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Why should PICC lines be changed every 7 days and prn?
a. The nurse supervisor mandates a weekly dressing change. b. Tests have proven that no infection will begin before a week. c. The dressing begins to irritate the skin of the client after a week. d. The client is at a high risk for infection at the insertion site. |
d. The client is at a high risk for infection at the insertion site.
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A client is brought to the emergency department with a T5 spinal cord injury from a car wreck. Which of these vital signs should the nurse expect to see the client exhibiting?
a. HR 120, RR 20, BP 100/68. b. HR 100, RR 16, BP 120/72. c. HR 62, RR 18, BP 110/50. d. HR 50, RR 32, BP 78/45.d |
d. HR 50, RR 32, BP 78/45.
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A client arrives at the hospital with full-thickness burns to the front and back of the right and left leg, the back of the right arm, and the anterior trunk. Upon arrival, the client's weight is 63 kg. Using the Parkland Burn Formula, how much IV fluids should the client receive during the first 24 hours?
a. 11,340 ml b. 13,104 ml c. 14.144 ml d. 14,742 ml |
d. 14,742 ml
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Which of the following is utilized to treat cholecystitis? Select all that apply.
a. Lithotripsy. b. Home remedies to dislodge the stone. c. Medications to break up the stone. d. Laparoscopic cholecystectomy. e. Open cholecystectomy. |
a. Lithotripsy
d. Laparoscopic cholecystectomy. e. Open cholecystectomy. |
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The nurse is caring for a client who underwent thyroidectomy with removal of parathyroid tissue following a diagnosis of thyroid cancer. The nurse notices twitches and spasms along the left lateral facial region. The nurse suspects which adverse outcome of the surgery?
a. Hypercalcemia b. Hyperkalemia c. Hypocalcemia d. Spread of cancer to mandibular glands
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c. Hypocalcemia
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The home care nurse observes that the client's supply of levothyroxine has 20 extra doses in the medication bottle. What assessment finding would be most consistent with underuse of the medication levothyroxine?
a. Constipation and fatigue b. Diarrhea and agitation c. Tachycardia and weight loss d. Exophthalmos and fine tremors e. Feeling cold and depressed |
a. Constipation and fatigue
e. Feeling cold and depressed |
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The nurse is preparing a teaching plan for a client with a new diagnosis of hypothyroidism and prescription for levothyroxine. Which adverse side effects will the nurse instruct the client? Select all that apply.
a. Palpitations and/or racing heart b. Sudden weight loss c. Delirium d. Diarrhea e. Weight gain |
a. Palpitations and/or racing heart
b. Sudden weight loss d. Diarrhea |
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The nurse is assessing a client with a history of cirrhosis and receives a report that the abdomen enlarged by 3 cm over the past 24 hours. The nurse contacts the health care provider because of which priority finding?
a. Pitting edema to lower extremities. b. Reddened 3 cm area to sacrum. c. Muffled heart sounds. d. Jaundice. |
c. Muffled heart sounds.
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The nurse is caring for a client who has undergone subtotal thyroidectomy. Which post-operative assessment should receive the highest priority?
a. Swallowing reflex b. Swelling in lower extremities c. Respiratory rate of 22 breaths/mind. d.Heart rate of 98 beats/min |
a. Swallowing reflex
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The nurse provides care for a client who is diagnosed with ascites and finds that the client's abdominal girth has increased by 7 cm over the past three days. The nurse determines the reasons for increased size includes which finding? (Select all that apply.)
a. Thirst occurs causing excess fluid intake b. Hyperaldosteronism increase sodium and fluid retention c. Liver is unable to synthesize albumin and decreased colloid oncotic pressure occurs d. Blood proteins are pushed out of the blood vessels, causing leakage into the peritoneal cavity e. Low blood pressure in the portal vein causing increased fluid retention |
b. Hyperaldosteronism increase sodium and fluid retention
c. Liver is unable to synthesize albumin and decreased colloid oncotic pressure occurs d. Blood proteins are pushed out of the blood vessels, causing leakage into the peritoneal cavity |
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The nurse is caring for a postoperative client 24 hours following a partial thyroidectomy for persistent hyperthyroidism. What assessment data should the nurse immediately report to the health care provider?
a. Change in Pulse Oximeter from 93% to 91% b. Change in respiratory rate from 30 to 22 c. Change in temperature from 99 F to 100.2 F d. Change in apical heart rate from 72 beats per minute to 94 beats per minute |
c. Change in temperature from 99F
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A 42-year-old female client arrives in the emergency department exhibiting RUQ pain radiating to the right shoulder, chills, tachycardia, and vomiting. The nurse suspects the client will be diagnosed with which condition?
a. Cholecystitis. b. Pancreatitis. c. Ulcerative colitis. d. Crohn's disease. |
a. Cholecystitis.
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The nurse receives a client from the recovery room after having a thyroidectomy. What most important interventions will the nurse perform during the next four hours? Select all that apply.
a. Keep 10% calcium gluconate available b. Assess back of neck c. Have tracheostomy set-up nearby d. Ambulate within 4 hours e. Assess the client's respiratory rate and rhythm |
a. Keep 10% calcium gluconate available
b. Assess back of neck c. Have tracheostomy set-up nearby e. Assess the client's respiratory rate and rhythm |
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A client questions the nurse about his prescription of famotidine for peptic ulcers. Which statement by the nurse appropriately explains the action of this medication?
a. "Famotidine works by decreasing stomach acid production." b. "Famotidine works by neutralizing gastric secretions." c. "Famotidine binds to the ulcer surface to protect the stomach." d. "Famotidine increases mucus to protect the stomach from ulceration." |
a. "Famotidine works by decreasing stomach acid production."
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The nurse goes into the room of a client with a chest tube. The nurse notices that the thoracic catheter has dislodged. Which action would the nurse take next?
a. Cover insertion site with petroleum jelly, apply firm pressure, notify the health care provider (HCP). b. Reconnect the thoracic catheter to the tubing or suction using clean technique. c. Obtain an order for a chest x-ray to identify malposition of the endotracheal tube. d. Administer supplemental oxygen via facemask and contact the health care provider (HCP). |
a. Cover insertion site with petroleum jelly, apply firm pressure, notify the health care provider (HCP).
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A client is brought into the emergency department with a gunshot wound to the chest. The nurse observes that the chest appears larger on one side and she hears crackling sounds as the client breathes and the client has jugular vein distention. The resident reports there is hyperresonance on percussion. Which action will most likely take place next?
a. Placement of a sterile occlusive dressing. b. Needle thoracostomy at the bedside. c. Immediate chest x-ray. d. Placement of oxygen with a nonrebreather. |
b. Needle thoracostomy at the bedside.
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A client has been newly diagnosed with chronic renal failure and will be receiving hemodialysis. Which statement describes the function of hemodialysis? Select all that apply.
a. Cleans the blood of waste products. b. Rids the body of excess fluids. c. Removes protein by-products. d. Abolishes the acid-base balance. e. Restores electrolyte levels. |
a. Cleans the blood of waste products
b. Rids the body of excess fluids. c. Removes protein by-products. e. Restores electrolyte levels. |
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A client was brought into the emergency department for smoke inhalation following a house fire. The nurse will monitor for which signs of acute respiratory distress syndrome (ARDS)? Select all that apply.
a. Low oxygen saturation with oxygen delivery at 80% FiO2 .b. Blood-tinged mucus and blood gases showing respiratory alkalosis. c. Tachypnea and use of accessory muscles. d. Bluish nail beds and restlessness. e. A productive cough with green sputum. |
a. Low oxygen saturation with oxygen delivery at 80% FiO2.
c. Tachypnea and use of accessory muscles. d. Bluish nail beds and restlessness. |
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The nurse is caring for a client just admitted to the intensive care unit for diabetic ketoacidosis (DKA). Which three priority treatments are critical during diabetic ketoacidosis?
a. Potassium replacement, insulin replacement, amiodarone therapy b. Fluid replacement, bicarb replacement, hypertonic saline infusion c. Fluid replacement, insulin therapy, and electrolyte correction d. Oral rinses, fluid replacement, bicarb replacement |
c. Fluid replacement, insulin therapy, and electrolyte correction
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Which will the nurse anticipate following surgery for stage 1 esophageal cancer?
a. Jejunal feeding tube b. Deep vein thrombosis c. 3+ periorbital edema d. Hospice consultationa |
a. Jejunal feeding tube
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The nurse is caring for a client with a pneumothorax and observes continuous bubbling in the water seal chamber. Which action by the nurse is best?
a. Continue to monitor. Continuous bubbling is expected b. Notify the health care provider (HCP) of the continuous bubbling. c. Encourage coughing and deep breathing. d. Change the client's position to promote ventilation. |
b. Notify the health care provider (HCP) of the continuous bubbling.
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The nurse is assisting the health care provider in the removal of a chest tube. How will the nurse instruct the client during the procedure?
a. "Breathe in and out while concentrating on a fixed object in the room." b. "Hold your breath and bear down while the tube is being removed to keep air from entering back into the area." c. "Do pursed-lip breathing then short huffing breaths while the tube is being removed to keep air from entering into the area." d. "Hold my hand and close your eyes while the tube is being removed since anxiety will cause you to breathe too quickly. |
b. "Hold your breath and bear down while the tube is being removed to keep air from entering back into the area."
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A client in the intensive care unit (ICU) with acute kidney injury is found to have tall, peaked T waves on the electrocardiogram (ECG). An order for administration of polystyrene sulfonate (Kayexalate) is prescribed. The nurse will continue to monitor for which complication the client is experiencing?
a. Hypokalemia. b. Hypercalcemia. c. Hyperkalemia. d. End stage renal failure. |
c. Hyperkalemia.
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The nurse contacts the healthcare provider about a client's assessment following chest tube removal and reports tracheal deviation away from the affected side, agitation, and neck vein distention, all signs of a tension pneumothorax. Which action will the nurse perform while waiting for re-insertion of the chest tube?
a. Release the dressing covering the open chest wound. b. Administer oxygen at 80% FiO2. c. Place the client in trendelenburg position. d. Perform arterial blood gas. |
a. Release the dressing covering the open chest wound.
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A client with diabetes mellitus type 1 admitted with DKA asks the nurse, "What causes DKA to happen?" The nurse correctly explains which common causes of DKA? Select all that apply.
a. Not taking oral antiglycemic medications b. Personal stress, such as starting college c. A recent, serious infection d. Having a recent stomach virus e. Taking too much regular insulin |
b. Personal stress, such as starting college
c. A recent, serious infection d. Having a recent stomach virus |
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The nurse explains to the client which medical history places the client at an increased risk for esophageal cancer? Select all that apply.
a. Barrett's esophagus b. Esophageal atresia c. Gastroesophageal reflux disease d. Human papillomaviruse. Tobacco and alcohol use |
a. Barrett's esophagus
c. Gastroesophageal reflux disease d. Human papillomavirus e. Tobacco and alcohol use |
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The nurse is caring for a client who has a chest tube following cardiac surgery and observes a dramatic decrease in chest tube drainage from the first hour to the second hour after surgery. Evaluation of the chest tube system indicates which problem?
a. The lungs are not at risk and are fully inflated. b. The client is recovering without further drainage. c. There may be tube obstruction due to a drainage clot d. Tension pneumothorax is pending, so call the health care provider immediately.
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c. There may be tube obstruction due to a drainage clot.
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A client is admitted for acute pancreatitis. Which symptoms will the nurse expect the client to demonstrate?
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d. Abdominal pain with radiation to the back.
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Which client is at the highest risk for pancreatitis?
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d. A 35-year-old male with long-standing alcohol abuse.
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While providing care to a client with a chest tube drainage system, the nurse detects redness around the insertion site of the tube along with subcutaneous crepitus. Upon palpation, the client denies any pain. Which action is best?
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a. Use a skin marker to identify the borders of the redness and continue to monitor.
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A nurse receives a client status post-kidney transplantation. Which clinical signs of graft rejection will the nurse monitor?
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a. A 2-3 lbs weight gain in 24 hours.
b. Edema. c. Hypertension. d. Pain over grafted kidney. |
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The nurse is assessing the chest tube drainage of a client with a hemothorax following a motor vehicle accident. Which findings will be expected in a normally functioning chest tube system? Select all that apply.
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a. Presence of an occlusive dressing over the insertion area.
b. Tidaling in the water-seal chamber with respirations. |
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The nurse is performing discharge teaching to a client who was diagnosed with acute pancreatitis. Which symptom of pancreatitis should the client report to the health care provider (HCP)?
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d. Clay-colored stools
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The nurse caring for a client with acute pancreatitis notices a carpal spasm while assessing blood pressure. Which action will the nurse perform next?
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c. Call the health care provider for a calcium level STAT.
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A client on the rehabilitation unit goes for hemodialysis for four hours. Upon return from dialysis, the nurse assesses the client's vital signs. The temperature is 100.3°. Which statement best reflects interpretation of the temperature following dialysis?
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b. Continue to monitor since rise in temperature is normal after dialysis.
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A client is being evaluated for pancreatitis. Which labs in the comprehensive metabolic panel, if critical will indicate to the nurse a diagnosis of pancreatitis?
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d. Amylase and lipase
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The client has been newly diagnosed with diverticulitis and is ready to be discharged. Gathering the client's discharge papers, the nurse should review what the client can do to reduce a recurrence. Which education will you review with the client? Select all that apply.
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a. Increasing fiber in the diet.
b. Exercise for at least 90 minutes per week. d. Take an OTC stool softener to prevent constipation e. Increase daily fluid intake to at least 2 Liters. |
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TPA for stroke |
Give 3-4 1/2 hrs after s/s start
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complications of Emboli stroke |
Afib |
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Iron
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Take with vit c, poop can be black, constipation can occur
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Precautions of thrombocytopenia
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Bleeding precautions
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signs & symptoms of DKA |
Polydispia, polyuria, polyphagia, fruity breath
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Unstable angina
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Not relieved with rest and unpredictable
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Right sided HF s/s
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-distended neck veins
-edema -enlarged organs -weight gain-ascites |
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Left sided HF s/s
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C- Cough
H- Hemoptysis O- Orthopnea P- Pulmonary Congestion (crackles/ rales) Pink frothy sputum |
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S/S of atelectasis
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Hypoxia, slow breathing, wheezy sound in lower lobes of the lungs
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S/s DVT
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Warmth, swelling, redness, and tenderness
DO NOT MASSAGE, elevate the legs, ambulate, and SCDs can help |
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At risk for metabolic acidosis
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People with diarrhea, kidney & liver failure, and diabetes |
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BPH
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At risk for UTI because urine retention (abnormal finding) Lab PSA
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stages of shock |
Compensatory stage (initial stage) Uncompensated stage (progressive shock) Refractory stage |
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SIRS s/s (systemic inflammatory response syndrome)
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need 2 of 4
temp <36 or >38 tachycardia (>90)tachypnea (>20bpm or PaCO2 <32) WBC (<4000 or >12000) |
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MODS
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evidence of 2 or more organs failing
homeostasis cannot be maintained without intervention arises following the activation of a host inflammatory response may be primary or secondary sepsis and septic shock are most common causes |
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anaphylactic shock management
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immediate administration of epinephrine
antihistamines steroids Remove allergens |
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Spinal Cord Injury s/s |
increased BP and RR flushed diaphoretic monitor for autonomic dysreflexia 1st raise HOB, check bladder or f/c for kinks and check for fecal impaction. |
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Spinal cord injury is r/t what shock |
neurogenic |
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Mass casualty priority patients |
Red (immediate) |
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Myxedema Coma |
severe thyroidism - decrease LOC, hypothermia, Bradycardia, constipation, puffy face, hair loss. Have trach kit at bedside |
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Care of patient with burns |
Focus is airway location of burns fluid resuscitation - LR 4mg/kg/total percent of body burned. half first 8 hrs, last half next 16 hours |
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care of patient with increased ICP |
Give osmotic diuretic (mannitol) causes: sneeze, cough, BM, straw symptoms: disorientation, irritable, ha, pupil changes |
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HIV pt assessment questions |
when did symptoms start sexual history physical assessment |
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care of patient in vfib |
dfib |
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how to prevent skin breakdown |
turn q 2 hrs no powders no massage keep dry |
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pt teaching with a pt with elevated cholesterol levels |
exercise and diet decrease cholesterol no fried foods, eggs |
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cardiogenic shock causes |
MI, CHF, Ventricular arrythmias |
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cardiac cath patient |
if done in R wrist check right radial pulse if done in R Groin check pulse in dorsal pedis |
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Difference between skeletal and skin traction |
skin traction less risk for infection skeletal traction pins into the bone @ risk for osteomyelitis, better to heal the fracture |
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Pt receiving prednisone |
increased irritablility decreased inflammation give with food or milk |
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care of pt with end stage liver CA |
treatment: ablation, embolization, or both immunotherapy, chemotherapy, radiation sx: abd px, fatigue, jaundice, digestive issues |
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pt with NG tube monitor for what |
decrease potassium (hypokalemia) |
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compensated shock |
normal v/s, start to see decrease LOC & U.O |
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Post op complications |
pneumonia atelectasis dehiscence - sterile drsg, no pressure illeus |
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Care of pt post op fractured mandible |
airway, airway, airway prevent aspiration. jaw wired shut, use a straw for nutrition intake |
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care of pt with skull fracture |
neuro checks battle sign monitor for nasal/ear drainage and check any drainage for sugar, CSF leak. DO NOT SUCTION |
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care of patient with leukemia |
decrease platelets, WBC's, RBC's. focus on leukocytes. neutropenia precautions |
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Care of pt's receiving cancer treatments |
neutropenic precautions: no fresh flowers no fresh fruits avoid crowds and sick people check temp q4hrs priority temp >100.3 |
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DVT prevention |
no airplane, ice, or massage early ambulation, keep hydrated and mobile, SCD's risks for dvt's : smoking, immobility, surgery, dehydration, pillow under knees |
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care of pt with aplastic anemia |
panscytopenia- (all cells are low) bone marrow issue |
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how to calculate a MAP |
2x diastolic + systolic divided by 3 |
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peptic ulcer disease |
lots of px in abdomen complications: bleeding, perforation (hole) gastric contents leaking absent BoSo |
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Diet for biliary colic and cholecystitis |
low fat, bland diet |
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ESRD (end stage renal disease) |
poor outcome decrease kidney function and GFR increase creatinine and BUN symptoms: confusion, jaundice, increased BP and RR uremia causes pruritis. toxins cause restless leg |
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hemodialysis |
weight and v/s before and after assess fistula |
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diverticulitis diet |
high fiber low residue (no popcorn, nuts) chicken and rice |
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endometrial cancer |
bleeding |
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kidney transplant |
monitor for rejection |
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care of pt with gun shot wound (sucking chest wound) |
place an occlusive dressing over sucking chest wound and give oxygen |
